舌下神经刺激器植入术中神经异常的挑战

摘要(中文译文)

舌下神经刺激（HGNS）是一种经美国食品药品监督管理局批准的治疗阻塞性睡眠呼吸暂停（OSA）的方法，适用于不能或无法耐受有争议的气道正压通气（CPAP）治疗的患者。然而，潜在的神经异常可能会损害手术疗效，需要术中适应性。我们报告了2例HGNS患者，他们患有影响神经形态的神经系统疾病。病例1涉及一名66岁的女性，她患有OSA（REI 52.5）和神经纤维瘤病（NF）。尽管舌运动正常，药物诱导睡眠内镜（DISE）检查良好，但术中发现舌下神经弥漫性增大。神经表现出微弱且不一致的刺激反应，袖带无法有效放置。程序已中止。术后MRI证实左侧舌下神经弥漫性增厚，与丛状神经纤维瘤一致。病例2为一名64岁男性，患有OSA（AHI 41.3）和慢性炎性脱髓鞘性多发性神经病（CIDP）。术中，舌下神经增大、牢固，且缺乏可识别的分支。混合刺激模式阻碍了功能性袖带的放置。采用对侧入路，成功植入并激活装置。这些病例突显了当NF或CIDP等神经异常改变神经结构或功能时，HGNS面临的挑战。神经纤维瘤可弥漫性浸润颅神经，使刺激复杂化，而CIDP可导致斑片状脱髓鞘和传导变异。术前成像，包括高分辨率T2加权MRI，对于评估神经形态和计划手术方法至关重要。外科医生必须为术中的可变性做好准备，包括可能需要对侧解剖。舌下神经异常会影响HGNS的成功。术前识别潜在的神经病变和适应性的术中计划对于优化复杂患者的预后至关重要。

Abstract

Hypoglossal nerve stimulation (HGNS) is an FDA-cleared therapy for obstructive sleep apnea (OSA) in patients who cannot or are unable to tolerate contentious positive airway pressure (CPAP) therapy. However, underlying neural anomalies may impair surgical efficacy and require intraoperative adaptability. We present 2 cases of HGNS in patients with preexisting neurologic conditions affecting nerve morphology. Case 1 involves a 66-year-old woman with OSA (REI 52.5) and neurofibromatosis (NF). Despite normal tongue motion and favorable drug-induced sleep endoscopy (DISE), intraoperative findings revealed diffuse enlargement of the hypoglossal nerve. The nerve exhibited weak and inconsistent stimulation responses, and the cuff could not be placed effectively. The procedure was aborted. Postoperative MRI confirmed diffuse left-sided hypoglossal nerve thickening consistent with a plexiform neurofibroma. Case 2 features a 64-year-old man with OSA (AHI 41.3) and chronic inflammatory demyelinating polyneuropathy (CIDP). Intraoperatively, the hypoglossal nerve was enlarged, firm, and lacked identifiable branches. Mixed stimulation patterns prevented functional cuff placement. A contralateral approach was pursued with successful implantation and device activation. These cases highlight challenges in HGNS when neural anomalies-such as those from NF or CIDP-alter nerve structure or function. Neurofibromas can diffusely infiltrate cranial nerves, complicating stimulation, while CIDP causes patchy demyelination and conduction variability. Preoperative imaging, including high-resolution T2-weighted MRI, is essential to assess nerve morphology and plan surgical approaches. Surgeons must be prepared for intraoperative variability, including the potential need for contralateral dissection. Anomalies of the hypoglossal nerve can compromise HGNS success. Preoperative identification of underlying neuropathies and adaptable intraoperative planning are critical for optimizing outcomes in complex patients.

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